Term Life Insurance Policy

TERM LIFE INSURANCE POLICY

Policy Number:    Insured Name:    Date of Birth:

Applicant / Owner Information

Policy Details

Policy Type: Level Term Decreasing Term Other    If Other (specify):

Coverage Options and Riders

The policy affords only the coverages and riders expressly elected and indicated below. Unchecked items are not included.

Waiver of Premium Rider    Accelerated Death Benefit Rider    Accidental Death Benefit Rider

Child Term Rider    Guaranteed Insurability Option    Other Rider:

Exclusions

Subject to the terms and conditions of this policy, the Company will not pay benefits for death caused or contributed to by:

1. Intentionally self-inflicted injury or suicide within the period stated in the policy;
2. Death while committing or attempting to commit a felony or while engaged in an illegal occupation;
3. War or any act of war, whether declared or undeclared, while on active duty in the armed forces of any country;
4. Participation in hazardous avocations if such participation is material to risk and not disclosed to the Company;
5. Any exclusion specifically endorsed to the policy at issuance or during policy amendment.

By signing this policy the Applicant acknowledges receipt and review of the above exclusions and that coverage is limited to perils not excluded herein: Acknowledged:

Beneficiary Designation

Primary Beneficiary Name:    Relationship:    Share %:

Contingent Beneficiary Name:    Relationship:    Share %:

Claims and Proof of Loss

Upon the death of the Insured, proof of loss must be furnished to the Company. Required items ordinarily include:

• Certified copy of the death certificate;
• Completed claim form signed by the claimant;
• Proof of the claimant's identity and relationship to the Insured;
• Medical records and autopsy report where reasonably required to establish cause of death;
• Any other documents reasonably necessary to determine entitlement to benefits.

Declarations, Conditions and Certifications

Incontestability: After this policy has been in force for two years during the lifetime of the Insured, statements made in the application shall be incontestable except for nonpayment of premiums and except as provided by any endorsement.

Misstatement of Age or Sex: If the age or sex of the Insured has been misstated, any benefit payable will be that which the premium paid would have purchased at the correct age or sex.

Suicide: If the Insured dies by suicide within the period specified in the policy, the Company shall have the rights provided in the policy, which may include limitation or denial of benefits as described in the policy provisions.

Grace Period: A grace period for the payment of premiums shall be provided in the policy. Coverage shall remain in force during the grace period subject to deduction of unpaid premium from any death benefit if applicable under the policy terms.

Reinstatement: The policy may be reinstated within the period specified in the policy subject to evidence of insurability satisfactory to the Company and payment of past due premiums with interest.

Conversion Privilege: If applicable, the Insured may have the right to convert this term policy to a permanent policy pursuant to the conversion provisions and subject to conditions indicated in the policy.

Authorization to Obtain Records

The Applicant authorizes any medical practitioner, hospital, pharmacy, insurance company, or other entity to release to the Company any records or information relating to the Insured or Applicant that is reasonably required to underwrite or adjudicate a claim. A photocopy of this authorization shall be as valid as the original.

Applicant's Certification

I hereby declare that the statements and answers contained in the application or supporting documents submitted in connection with this policy are true and complete to the best of my knowledge and belief. I understand that any false statement or omission in such documents may allow the Company to void coverage or deny benefits to the extent permitted by law and by the terms of this policy.

I authorize the Company to deduct any applicable policy fees or premium payments from the method of payment on file and acknowledge that acceptance of premiums does not constitute a waiver of the Company's rights. I further acknowledge that I have received a copy of this policy and that this policy is issued in reliance upon the representations contained herein.

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